DCMedical News: Wednesday, February 7, 2018
DCMedical News
Washington, D.C.
Wednesday, February 7, 2018
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THE BIG STORY TODAY IN HEALTH CARE
The Continuing Resolution (#5) Passed by the House Tuesday Night is a Major Health Bill Attached to a Measure to Continue Funding of the Government . . . But It Pits Public Health Supporters Against Clinical Services Providers
The Continuing Resolution (two page version from DCMN of February 6 here, twenty nine page summary of provisions here, 515 page full CR #5 here, Committee leaders’ summary of highlights here) must now be considered by the Senate, where sixty votes will be needed. The impact of this bill will be felt by doctors and other health professionals, hospitals and other organizational providers, insurers and patients, see details below.
Provider interest in the CR is high, and will continue to grow as its provisions become more widely known. The source of funds to offset some of the provisions in this bill, on the other hand, the “Prevention and Public Health Fund,” (PPHF) is also defended, generally by those who benefit.
The PPHF was one of the many creations of the Patient Protection and Affordable Care Act (PPACA), in Title IV, section 4002, as chronicled by John McDonough in his comprehensive (you-are-there) telling of the creation of PPACA, Inside National Health Reform, (University of California Press, Milbank, 2011). McDonough notes that, unlike traditional authorization and appropriation measures, PPHF “receives a direct appropriation embedded in the statute” (pg. 187). A total of $15 billion was so embedded, and was derided by some Senate Republicans as “a ‘slush fund’ for jungle gyms and walking paths.”
McDonough noted that, even before the statute was implemented, half of the first year’s PPHF funds were siphoned away for “workforce development” purposes, because “there was insufficient time in the four months remaining in federal fiscal year 2010 to spend all available funds on public health need” (pg. 188). McDonough presciently foresaw that the ease with which these funds were diverted—public health to workforce—might pave the way for other diversions, and specifically he wrote that “the bigger issue will be the attitude of the new Republican-controlled House of Representatives.” There is already another precedent for diverting these funds: Democrats agreed in 2016 to cut the fund as part of the “21st Century Cures Act” in order to support medical research.
So now we know what the bigger issue leads to—the use of the “slush fund” or “prevention trust,” depending on your point of view, as “pay-fors” in this CR. The funds are being diverted to meet the current needs of patients seen in community health centers, safety net hospitals and the offices of physicians caring for Medicare beneficiaries. CR #5’s offsets include nearly $2.9 billion in cuts over a decade to the PPHF.
Below is discussion of the most prominent of the many health provisions contained in the 515 pages of what might otherwise appear to the general public to be a bill “keeping the government running.” Other issues (defense vs. domestic spending, wall vs. no wall, DACA, borders, etc.) may determine the fate of CR #5.
DSH (Disproportionate Share Hospital) is a $12 billion program for which Congress previously delayed cutbacks, taking effect finally October 1 of 2017. CR #5 eliminates $5 billion in scheduled cuts to DSH payments that were set to take effect this year and next. (The sum total of DSH cuts, $43 billion, will continue through fiscal year 2025. The cuts were also part of PPACA, the theory being that DSH would no longer be needed by safety net hospitals, on grounds that patients who formerly were “self pay”—a/k/a no pay—would instead have their medical care paid for through expansion of the Medicaid program, or through subsidy of individual policy premiums and cost-sharing for those not eligible for Medicaid but still medically indigent. Medicaid was not expanded in 19 states, however, and cost-sharing reduction payments were eliminated. Most poignantly, some safety net hospitals discovered that their patients, armed with Medicaid, went elsewhere for medical care.)
CR #5 provides $3.6 billion for community health centers for each of the next two years. An important letter of support for the Community Health Centers was organized by House Member Rep. Elise Stefanik (here), and another signed by two- thirds of the Members of the Senate (here).
All section citations below are taken from CR #5, verbatim.
DOCTORS and OTHER HEALTH PROFESSIONALS
These provisions of import for physician pay rates under Medicare:
Section 2112: Extension of work Geographic Practice Cost Indices (GPCI) floor. Medicare payments to physicians are geographically adjusted to reflect the varying cost of delivering physician services across areas. The adjustments are made by indices, known as the Geographic Practice Cost Indices (GPCI) that reflect how each geographic area compares to the national average. In 2003, under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Congress established that for three years there would be a “floor” of 1.0 on the “work” component of the formula used to determine physician payments, which meant that physician payments would not be reduced in a geographic area just because the relative cost of physician work in that area fell below the national average. Congress has extended the work GPCI floor several times since then, the most recent extension included in MACRA, expired on January 1, 2018. This section would provide a two-year straight extension of this policy until January 1, 2020.
MACRA: CR # 5 would give the Centers for Medicare and Medicaid Services flexibility for three years in calculating doctors’ cost of services under the law's payment formula, a priority for the American Medical Association. The “pay-for,” however, an extension of payment reduction for “misvalued” billing codes, is opposed by the AMA, see letter here. Still, CR #5 has this provision: Section 2704: Extension of target for relative value adjustments for misvalued services and transitional payment rules for certain radiation therapy services under the physician fee schedule. In 2010 Congress mandated that CMS start developing metrics to identify codes in the physician fee schedule that were misvalued. Since then Congress has sped up the process of identifying these codes and applied a minimum level of codes that needed to be found and adjusted in the fee schedule for multiple years. For 2018, CMS was able to identify .41-percent in negative adjustments of the 0.5-percent target in statute. This legislation would extend the policy of identifying misvalued codes for one more year.
This provision of import to providers of therapy services, and their patients:
Section 2113: Repeal of Medicare payment cap for therapy services; replacement with limitation to ensure appropriate therapy Medicare beneficiaries face a cap for all Medicare-covered outpatient therapy services. Established by the Balanced Budget Act of 1997 (BBA 97), these limits are applied to therapy services provided by nonhospital providers, to be applied separately for: (1) physical therapy (PT) services and speech-language pathology services; and (2) occupational therapy (OT) services. Congress has never let the cap go into effect for any year for all services realizing the potential harm to limiting beneficiary access to these services and has since legislated a higher cap after a series of delays to the enforcement of the cap, and instituting an exceptions process through the Centers for Medicare and Medicaid Services (CMS) for exceeding the cap if extra services are “reasonable and necessary.”
In 2006, Congress established an exceptions process to allow providers and practitioners to request an exception to the therapy caps on behalf of a beneficiary when the additional services are reasonable and necessary. MACRA extended this exceptions process through Dec. 31, 2017, and it also required the HHS Secretary to implement a targeted manual medical review process for outpatient therapy services. This section would permanently repeal the outpatient therapy caps beginning on January 1, 2018. It would continue to require that an appropriate modifier be included on claims over the current exception threshold indicating that the services are medically necessary, and it would lower the threshold for the targeted manual medical review process from $3,700 to $3,000.
These provisions of import for community health centers and also for physicians in training:
Section 2501: Extension for community health centers, the National Health Service Corps, and teaching health centers that operate GME programs. This section extends the funding for Community Health Centers for two years and implements technical and programmatic changes that improve the health centers’ ability to function in the modern health care landscape. Combined with funding provided in the December Continuing Resolution (H.R. 1370), Community Health Centers will receive $3.6 billion for each of FY2018 and FY2019. Section 501 also extends for two years, the funding for the National Health Service Corps and the Teaching Health Center Graduate Medical Education Program. Combined with funding provided in the Disaster Tax Relief and Airport and Airway Extension Act (H.R. 3823) and H.R. 1370, for each of FY2018 and FY2019, the National Health Service Corps will receive $310 million and the Teaching Health Center Graduate Medical Education Program will receive $126.5 million.
This provision one of a number concerning telemedicine:
Section 2315: Expanding the use of telehealth for individuals with stroke. Currently, Medicare pays for physician services involved in stroke treatment under the Physician Fee Schedule, with the hospital being paid under the Hospital Outpatient Prospective Payment System and Inpatient Prospective Payment System. While many of these physician services are furnished on-site when the beneficiary presents symptoms of stroke at the hospital emergency department, Medicare will pay a physician, at a distant site, for consulting on a patient experiencing acute stroke symptoms via telehealth if the originating site hospital, where the beneficiary presents, is in a rural HPSA or a county outside an MSA.
This section would expand the ability of patients presenting with stroke symptoms to receive a timely consultation to determine the best course of treatment through telehealth, beginning in 2021. Specifically, it would eliminate the geographic restriction as to permit payment to a physician furnishing the telehealth consultation service in all areas of the country for the purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.
HOSPITALS AND HEALTH CARE FACILITIES
Section 2712: Modifying reductions in Medicaid DSH allotments. Eliminates the Medicaid DSH reductions scheduled for FY2018 and FY2019 under current law. The DSH reduction of $4 billion in FY2020 under current law remains, and the bill adds a total of $6 billion in additional DSH reductions to offset the cost of eliminating the FY2018 and FY2019 reductions. These reductions are: in FY2021 ($3 billion), FY2022 ($2 billion) and FY2023 ($1 billion).
This provision will be of import for the future of home health care:
Section 2201: Home health payment reform. This section requires the Secretary to reform the current home health payment system, beginning January 1, 2020. The Secretary is required to implement a 30-day episode for payment. This change is required to be budget neutral. See also sections 2202 on eligibility determination and 2203 on settlement of claims.
Rural and low volume hospital provisions:
Section 2101: Extension of the Medicare-dependent hospital (MDH) program. MDHs are small, rural hospitals with a high proportion of patients who are Medicare beneficiaries. MDHs receive special treatment, including higher payments. To be eligible for the MDH program, hospitals must have no more than 100 beds and at least 60 percent of their acute inpatient days or discharges must be for Medicare patients. Congress has extended the MDH program several times, the most recent extension included in Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), expired on October 1, 2017. This section would provide a two-year straight extension of this policy until October 1, 2019.
Section 2102: Extension of increased inpatient hospital payment adjustment for certain low-volume hospitals. Qualifying hospitals receive increased payments to account for the higher incremental costs associated with a low volume of discharges. Current thresholds to qualify for the program are set at less than 1,600 discharges and more than 25 road miles from another acute-care hospital. Congress has extended the low-volume program several times, the most recent extension included in MACRA, expired on October 1, 2017. This section would provide a two-year straight extension of this policy until October 1, 2019.
Section 2205: Extension of enforcement instruction on Medicare supervision requirements for outpatient therapeutic services in critical access and small rural hospitals. This section prevents Medicare’s enforcement of unreasonable and inflexible direct supervision rules for outpatient therapy services at Critical Access Hospitals (CAHs) and other small, rural hospitals for 2017. An annual extension bill has been passed into law since 2014.
Additional provisions of import for rural health care:
Section 2104: Extension of home health rural add-on. Medicare provides increased payments under the home health (HH) prospective payment system (PPS) for home health care provided to beneficiaries in rural areas. MACRA extended the 3-percent Medicare HH PPS rural add-on through December 31, 2017. This section would provide a 5-year extension of this policy with reforms until October 1, 2022. The reforms in this section include a new methodology to target the add-on payment to those areas with a population density of 6 or fewer individuals per square mile.
Section 2111: Ground ambulance services cost reporting requirement. This section would extend the 2-percent urban, 3-percent rural, and 22.6-percent super rural ground ambulance add-on payments for five years. The section would require annual cost reporting, by adding providers and suppliers of ground ambulance suppliers as a new category. Congress has extended the ambulance add-ons several times, the most recent extension included in MACRA, expired on January 1, 2018. This section would provide a five-year extension of this policy until December 31, 2022.
HEALTH INSURANCE, MEDICARE, MEDICAID, COMMERCIAL
This provision of import to patients in Medicare Advantage (MA) programs:
Section 2121: Providing continued access to Medicare Advantage special needs plans for vulnerable populations
Special Needs Plans (SNPs) are Medicare Advantage (MA) plans that provide services for individuals with special needs. SNPs are permitted to target enrollment to one or more types of special needs individuals, including those who are: (1) institutionalized; (2) dually eligible for both Medicare and Medicaid; or (3) living with severe or disabling chronic conditions. Congress has extended SNPs several times, but the most recent extension (which was included in MACRA) expires on January 1, 2019. This section permanently reauthorizes SNPs, along with a number of reforms to D-SNPs and C-SNPs that will improve care management.
Section 2311: Adapting benefits to meet the needs of chronically ill Medicare Advantage enrollees. Currently, a MA plan must offer the same benefit package to all of its enrollees. The Centers for Medicare and Medicaid Innovations (CMMI) is currently testing a model to allow greater flexibility for an MA plan to meet the needs of chronically ill enrollees. This section would expand the testing of the CMMI Value-Based Insurance Design (VBID) Model to allow an MA plan in any state to participate in the model by 2020.
Section 2312: Expanding supplemental benefits to meet the needs of chronically ill Medicare Advantage enrollees. An MA plan must adhere to specific rules regarding the supplemental benefits that it can offer. This section would allow an MA plan to offer a wider array of targeted supplemental benefits to chronically ill enrollees beginning in 2020. These supplemental benefits would be required to have a reasonable expectation of improving or maintaining the health or overall function of the chronically-ill enrollee and would not be limited to primarily health related services.
Section 2313: Increasing convenience for Medicare Advantage enrollees through telehealth. This section would allow an MA plan to offer additional, clinically appropriate, telehealth benefits in its annual bid amount beyond the services that currently receive payment under Part B beginning in 2020. The Secretary of HHS would be required to solicit comments on: what types of telehealth services should be considered to be additional telehealth benefits and the requirements for furnishing those benefits. If an MA plan provides access to a service via telehealth, the MA plan must also provide access to that service through an in-person visit, and the beneficiary would have the ability to decide whether or not to receive the service via telehealth.
PHARMA and OTHERS
There are another two dozen “health” provisions in this Continuing Resolution. More of the prominent ones in tomorrow’s edition of DCMN.
EVENTS & MEETINGS
Your February & March Calendar:
February 13
12:30 to 5:00, the ONC and the ASPE present a webinar on “Blockchain in Healthcare,” agenda and registration page here.
March 1
MedPAC, Ronald Reagan Building, Horizon Ballroom, 1300 Pennsylvania Ave, continuing March 2.
March 1
MACPAC, advisory body on Medicaid and the Children’s Health Insurance Program, continuing March 2.
March 26
PTAC, Physician-Focused Payment Model Technical Advisory Committee, continuing March 27, information at www.regonline.com/PTACMeetingsRegistration or livestream at www.hhs.gov/live.
For reference:
Members of the Senate (here) and Members of Senate Committees (here), Senate Calendar (here).
Members of the House with their House Committees (here), House Calendar (here).
DCMN: February publication dates: 8, 9, 12, 13, 14, 15, 16, 26, 27, 28.
Notes to: Fred Hyde, MD, JD, MBA; fredhyde@aol.com